New Patient Forms PATIENT DETAILS Patient's First Name Patient's Last Name Nickname Patient's Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip GenderGenderFemaleMale Home Phone Date of birth Age Cell Phone School/Employer Grade/position Work phone How did you hear about our office Email Family members treated in our office Reason for Consultation Dentist Date of last cleaning YesNoHas the patient been examined by an orthodontist before? If the Guardian & the Patient are the same person, please click here to copy patient information below. GUARDIAN #1 / INSURANCE INFORMATION Self Spouse Father Mother Stepparent Other (specify) Guardian's First Name Guardian's Last Name Home Phone Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Employer Work Phone Date of birth Social Security Number Cell Phone Guardian's E-Mail ORTHODONTIC INSURANCE (IF APPLICABLE): Company Name Phone Subscriber/Member ID GUARDIAN #2 / INSURANCE INFORMATION YesNo Is there a second guardian and / or additional insurance to add? Self Spouse Father Mother Stepparent Other (specify) Guardian's First Name Guardian's Last Name Home Phone Address City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Employer Work Phone Date of birth Social Security Number Cell Phone Guardian's E-Mail ORTHODONTIC INSURANCE (IF APPLICABLE): Company Name Phone Subscriber/Member ID r Payment Policy By checking this box, I authorize my insurance company to pay the dentist all insurance benefits rendered I authorize the use of this electronic signature on all insurance submissions I authorize the dentist to release all information necessary to seecure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. SLEEP / AIRWAY ISSUES YesNoDoes the patient tend to be a mouthbreather? YesNoDoes the patient snore at night? YesNoDoes the patient seem rested in the morning? YesNoIs the patient often sleepy during the day? YesNoHas the patient seen an Ear, Nose & Throat Specialist? YesNoIs the patient using a sleep apnea device? DENTAL/MEDICAL HISTORY Please check if the patient has a history of the following medical conditions: YesNoAcid Reflux YesNoADHD/ADD YesNoAIDS/HIV YesNoAnemia YesNoArthritis YesNoAsthma YesNoAutism YesNoBone Disorders YesNoCancer YesNoCerebral Palsy YesNoChest Pain YesNoChronic Neck Pain YesNoClicking of Jaw YesNoJaw Pain YesNoCold Sores/Herpes YesNoDiabetes YesNoDown Syndrome YesNoEndocrine Problems YesNoEmotional Disorders YesNoEpilepsy YesNoHeadaches YesNoHeart Condition YesNoHepatitis YesNoEar Pain YesNoImmune Problems YesNoKidney Problems YesNoLow Blood Pressure YesNoMuscular Disorders YesNoNervous Disorders YesNoOrgan Transplant YesNoOsteoporosis YesNoPainful Chewing YesNoPeriodontal Problems YesNoProlonged Bleeding YesNoRheumatic Fever YesNoScoliosis YesNoSeizures YesNoSinus Problems YesNoTMJ Problems YesNoTuberculosis YesNoDo your gums bleed when you brush? YesNoIs the patient seeing any other dental specialists? YesNoAny dental restorations needing to be completed? YesNoHave there ever been any injuries to the face, mouth or chin? YesNoHave you ever lost or chipped any teeth? YesNoDo you have any pain or soreness around your face, neck or back? YesNoIs any part of your mouth sensitive to temperature or pressure? YesNoIs the patient currently pregnant? YesNoIs the patient currently nursing? YesNoHave adenoids been removed? YesNoHave tonsils been removed? YesNoCurrently taking any medications? YesNoAre antibiotics necessary prior to treatment? YesNoAllergies? YesNoAny diseases or problems not mentioned above? Please check if the patient has, or ever had, any of the following habits? YesNoCheek, tongue or lip biting YesNoClenching Teeth YesNoFingernail Biting YesNoGrinding Teeth YesNoTongue Sucking YesNoThumb Sucking YesNoTongue Thrusting HIPPA / Financial Policy Acknowledgment Consent for Services and Financial Policy As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made. Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms and will credit any collections to the patient's account. A service charge of 1.5% per month (18% per annum) on the unpaid balance will ba charged on all accounts exceeding 30 days, unless previously written financial arrangements are satisfied. I understand there will be a $30.00 fee for returned checks. I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunqer shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment. By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature HIPAA Acknowledgement I understand that I may inspect or copy the protected health information described by this authorization. I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality. By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature SIGNED CONSENT By Checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes Consent for Internet Communications I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I am responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice website with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns. I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload, and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the website on my behalf. I understand that the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED, OR RECEIVED USING THE SITE OR THE SERVICES I hereby authorize this office to perform an orthodontic evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate dental treatment on the above-named patient. I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments. I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information, and clinical information) to the secured website for the dental practice. Typed Name/Signature Relationship to Patient Date If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here: By submitting this form you agree to the above mentioned consent statement Submit Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.